=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891910055
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA L DAUGHERTY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1312 BETTY JANE ST
-----------------------------------------------------
City | BEAVER DAM
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42320-1333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-274-8204
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1312 BETTY JANE ST
-----------------------------------------------------
City | BEAVER DAM
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42320-1333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-274-8204
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255R0406X
-----------------------------------------------------
Taxonomy Name | Blind Rehabilitation Specialist/Technologist
-----------------------------------------------------
License Number | 01929
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------